Model Release Document

I, Doli Hutabarat the undersigned model, from now will be referred to

as "Model" in this document, give to
Doli Hutabarat (Photographer), his/her
legal representatives and successors, as well as persons or corporations,
including Dreamstime.com acting with his/her permission,unlimited
permission to user, and/or publish and/or copyright photographic
portraits or pictures of the Model, and the negatives, prints,
transparencies or digital information relevant to them,in which the
Model may be included in whole or partly, or modified in form, or
reproductions thereof, in color or otherwise, made through any media
means in the Photographer's studioor elsewhere for art or any other
lawful purpose, in any format, still, single, multiple, moving or video.
Hereby I renounce any right that I may have to inspect and approve the
finished productor copy that may be used in connection with an image
that the Photographer has taken of the Model, or the use to which it
may be applied. Furthermore, I release the Photographer, or
others,specifically Dreamstime.com, for whom he/she is acting, from any x MALE FEMALE
claims of pay associated with any form of damage, be it foreseen or un
foreseen, related with the proper artistic or commercial use of these Black or African
Asian American
images, unless it can be proven beyond any doubt that mentioned
reproduction was caused maliciously, or produced and published with Caucasian/White Hispanic

the sole purpose of causing the Model to besubjected to scandal, ridicule, Multi-racial x Other
reproach, scorn and indignity. I acknowledge that the photography
session took place in a completely correct and professional manner, and
this release,was signed willingly at its termination. I certify that I am not
a minor, and am free and able of giving such consent.

Doli Hutabarat 1 1 2 5 1 9 9 6

MODEL'S FULL NAME* MODEL'S DATE OF BIRTH(MM DD YYYY) *

MODEL'S SIGNATURE *

Tembesi Raya Blok B No 10 29438

MODEL'S STREET ADDRESS * POSTAL/ZIP CODE *

+ 6 2 8 1 2 6 2 3 4 1 4 8 Batam

7 TOWN/CITY *

MODEL'S PHONE WITH INTERNATIONAL COUNTRY CODE *

dolihutabarat695@gmail.com Indonesia
MODEL'S E-MAIL ADDRESS * COUNTRY *

Hereby, the undersigned Photographer grants to the Model permission to use and/or display, and or publish photographic
portraits or pictures, and/or digital information relevant to them, in which the Model may be included in whole or partly, or
modified in form, or reproductions thereof, in color or otherwise, in any format, still, single, multiple, moving or video, made
through any media or lawful promotion of the Model, as long as the copyright of the Photographer is clearly presented with the
image.

1 2 1 2 2 0 2 2 Doli Hutabarat
PHOTOGRAPHER'S SIGNATURE *
DATE (MM DD YYYY) * PHOTOGRAPHER'S FULL NAME *
Bonggas Hutabarat
WITNESS SIGNATURE *
WITNESS FULL NAME *

This for will be retained with all negatives, transparencies, source files, and/or contact sheets.

Phone: +1 615-771-5611 * office@dreamstime.com * www.dreamstime.com

MR generated in "Dreamstime Companion" v7.2.1, dated 12/12/2022.